BUPRENORPHINE PROGRAM TREATMENT CONTRACT

As a participant in the buprenorphine treatment for Opioid Use Disorder (OUD), I freely and voluntarily agree to accept this treatment contract as follows:

1. ​I agree to keep and be on time to all my scheduled appointments. 

2. I agree to adhere to the payment policy outlined by this office.

3. I agree to conduct myself in a courteous manner in the doctor's office.

4. I agree not to sell, share, or give any of my mediation to another person. I understand that such mishandling of my mediation is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal. 

5. I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor's office. 

6. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my buprenorphine I filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without any recourse for appeal.

7. I agree that my mediation/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my mediation/prescription until the next scheduled visit. 

8. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost. 

9. I agree not to obtain medications from any doctors, pharmacies, or other sources without telling my treating physician. 

10. I understand that mixing buprenorphine with other medications, especially benzodiazepines (for example, Valium(R), Klonopin(R), or Xanax(R)), can be dangerous. I also recognize that several deaths have ocurred among personals mixing buprenorphine and benzodiazepines (especially if taken outside the care of a physician, using routes of administration other that sublingual, or in higher than recommended therapeutic doses).

11. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor. 

12. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling at a minimum of twice monthly or more frequently if clinically necessary. 

13. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substance (with the exception of nicotine).

14. I agree to provide random urine samples and have my doctor test my blood alcohol level. I agree to pay $34.00 for the expenses associated with the process of urine collection for the drug screening analysis. I understand that this fee is not payable by any insurance company and is a separate fee from the cost of the urinalysis.

15. I understand that violations of the above may be grounds for termination of treatment.